Getting ready to face the future

Judith Monroe kicked off today's afternoon session with jellyfish. Not actual jellyfish (though that would've been one seriously memorable session). A story about jellyfish.

Monroe, who's deputy director of the Centers for Disease Control and Prevention, told the story of Jellyfish Lake, which is located in the Rock Islands of Palau. Millions of years ago, Jellyfish Lake formed as a landlocked saltwater lake, and the jellyfish got trapped, never to go to the ocean again. So they began to adapt. Their new environment didn't have the same old predators, so the jellyfish lost their stingers. They freely swim to the top of the lake to get sunlight and to the bottom to get rich nitrogen. The jellyfish have the lake to themselves — as Monroe said, they have a pretty good life.

Of course, this isn't a story entirely about jellyfish. Monroe was using it as a metaphor for the kind of adaptation and transformation that public health must undergo as well. During the Wednesday afternoon session on "Visions of the Future: A Leadership Challenge," Monroe, who moderated the session, said public health has to contemplate three things: What should we continue doing, what should we start doing and what should we stop doing.

Massachusetts Health Commissioner John Auerbach told attendees how his state has been transforming and adapting. Six years after the state adopted its own health reform law, 98 percent of Massachusetts residents, including 100 percent of children, are insured. But there's still work to be done, Auerbach said. He said there are five new challenges and skills that public health needs to work on.

First, zero in on the social and economic conditions that affect people's health and employ effective policy to shape those conditions. Second, hone new skills, enhance analytical skills and learn about health information technology. Third, clarify who the payers are and what the responsibilities of public health are. Fourth, be better at demonstrating the value of public health work, particularly prevention (ideally, he said public health should be able to show insurers the return on investment within 18 months). And fifth, link population health and clinical care, and provide input on what quality care entails.

Lillian Shirley, president of the National Association of County and City Health Officials, noted that each jurisdiction will have to struggle according to its own circumstances to make progress. Then Shirley made a well-received shout-out to her fellow nurses, calling on attendees not to overlook the contributions of the nursing workforce. (For example, she said folks in her state of Oregon are "hysterical" over a Medicaid expansion because they say there's not enough doctors; to which Shirley says: what about the role of nurses? Cue more applause.)

"How are we going to knit together all these really great things that are going on...and make it a system transformation," she said. "We have to put our shoulder to the wheel on that one."

Nancy Terwood, East Great Lakes regional director of the National Association of Local Boards of Health, called on attendees to "look at your board of health member as an untapped resource." She noted that board of health members "really are the voice of local public health...we can be your legs, your voices, your arms." Unfortunately, she said that a recent association survey found that boards of health members desperately need training in a variety of areas, including how to do self-assessments and how to advocate for public health. Boards of health members, she said, "want to learn about helping you."

When it comes to the health of American Indian communities, Paul Allis, director of public health programs at the National Indian Health Board, said there's been a lot of progress on partnerships between federal health officials and tribal ones. He noted that the movement toward accreditation is helping to elevate public health within tribal communities. Though he did say that tribal leaders want to interact with state, local or federal leaders, "from nation to nation."

Public health, Shirley said, attracts people to it because of its mission, vision and values. We're attractive to people who want to change the world, she said, so let's "capture that excitement."

A little birdie told me so: Tweet of the day

Today's Tweet of the Day goes to Twitterer @Sarahwk, who said:

Learning about tribal health issues at #APHAmid12. Wow — a lot of needs and not an area you hear about a lot. Would like to hear more.

No problem! Check out these fantastic resources from the Indian Health Service, the National Library of Medicine and the National Indian Health Board.

Working lunch

Midyear meeting attendees participated in roundtable sessions on a variety of topics during Wednesday's lunch hour.

Public health gets with tech

Steve Cline started with a disclaimer: "I'm not an IT geek." Still, the coordinator for health information technology at the North Carolina Department of Health and Human Services, says he has a lot of appreciation for what technology has done — and most definitely will do — for the public's health.

"I really believe health (information technology) is a new frontier for public health that we really need to embrace," he told attendees at a Wednesday morning session on "Technological Strategies to Advance Public Health."

Next Cline asked attendees an interesting question: Why do we tolerate such poor information technology in health? We wouldn't accept it in many other aspects of our lives. (Seriously, how many times have we all stopped what we were doing to curse our slow telephone, computer, insert any electronic gizmo here.) But when it comes to health, barely an audible peep. The technology for medical interventions has made enormous leaps and bounds, but in terms of the overall operation of the health system, we have a long way to go, Cline said.

Fortunately, North Carolina is helping to lead the way toward a more tech-savvy health system. The goals of the state's health information technology efforts, which has more than $1 billion invested in its development, are: improved quality, better health, controlled costs and better engagement with health care consumers.

"North Carolina is really living out the concept that public health must be more integrated with clinical care and medical providers if we're to be relevant and sustainable," Cline said.

A couple examples of North Carolina's successes: Community Care of North Carolina, which is comprised of 14 networks of providers committed to caring for Medicaid, Medicare and uninsured patients, is busy investing in an informatics center that will create a systems-wide approach to patient care and foster new, innovative models of delivery. Also, the North Carolina Community Health Information Portal, which is still under development, is taking "huge amounts of data and turning that into compelling stories" to help us do the work of public health, Cline said.

Information technology reform is health care reform, he told attendees.

Daniel Jensen, associate director of public health at Olmsted County Public Health Services in southeast Minnesota, was described during his introduction as an evangelist for public health information exchange. Jensen told attendees about the impressive amount of work that public health has done to bring communities of care together via improved information technology.

For example, the public health agency is working to coordinate better asthma care between parents, providers, public health and schools. Today, just through improving the "paper sharing" process, there's 2,500 asthma action plans now on file with school nurses. When the effort began, less than 400 such plans were on file despite the more than 5,000 students who had serious asthma problems. Now, the focus has turned to building an online portal for school nurses so no matter which school they're working at, they'll know which kids have asthma and how to be prepared in case of an asthma attack.

"We can build better systems," Jensen said.

Public health + medicine = healthy people

The Institute of Medicine's J. Michael McGinnis presents during Wednesday
morning's session on public health and clinical care.

Medicine cannot exist without public health. Public health cannot exist without medicine. That’s the case made by physician and long-time health leader J. Michael McGinnis, MD, MPP, during this morning’s Midyear Meeting plenary session on integrating public health and clinical care.

“The relationship between medicine and public health … is in my view the central health policy issue of our time,” said McGinnis, a senior scholar at the Institute of Medicine.

He described the continuum of care: “At one end are those prevention efforts that are exclusively targeted to an entire population to the other end where treatment is targeted exclusively to one individual or patient. The other [interventions] lie scattered like a bell-shaped curve in the middle.”

He founded his case on three points:

1.    Medicine cannot provide effective and informed treatment to the patient without public health.
2.    Public health cannot advance the health of the population without medicine.
3.    The nation’s health and economic security will be at a disadvantage as long as financial incentives work in the middle.

McGinnis, a long-time member of APHA, argued that the 10 greatest public health achievements of the last century as outlined by the Centers for Disease Control and Prevention, such as vaccinations, healthy work places, motor vehicle safety and control of infectious disease, “are all a result of close collaboration between medicine and public health.”

So what happened to cause a split between the two communities?

“Throughout the 1960s, it was the success of this partnership that ironically frayed the ties,” according to McGinnis. The extension of the lifespan brought an increasing prevalence of chronic conditions and a more medically needy population around which developed a vast network of highly technical interventions and diminished attention to public health. And that was compounded by a dramatic change in financing with the creation of Medicare and Medicaid.

“Health expenditures going to prevention fell to below 5 percent, which is where it sits today,” he said. “What’s really changed are the economic incentives.”

He pressed his case for increased collaboration, asking the full room of meeting attendees to consider CDC Director Tom Frieden’s winnable battles, including food safety, immunizations, health care-associated infections, mother-to-child infection of HIV, motor vehicle injuries and tobacco use.

“How many of these battles can only be won by public health? How many can only be won by medicine?” he asked. “Virtually none.”

But, as he sees it, collaboration is trending. McGinnis pointed to a long list of items that are forging the relationship between medicine and public health, including an aging population, the potential for bioterrorism, information technology and new and emerging infectious diseases.

“It’s very clear that vigilance (on communicable disease) cannot be practiced effectively without very tight seamless communications between those treating them and those watching the habits of those individuals,” he said.

And regarding the impact of rising health care costs, “we already see that $2.7 trillion [in annual health care spending] is driving a stronger focus on prevention and public health. It’s a good thing, but it’s coming at a very high price.”

And with the Supreme Court opinion on the Affordable Care Act pending, “we hope tomorrow that those (prevention) elements will be retained,” as those are among the most important provisions, he said.

Despite the formidable challenges of the future, “I’m optimistic because I know the public health community. And I believe we’re seeing a ‘greening’ of the medical community,” McGinnis said.

By that, he meant in four ways: (1) the environmental sense — taking medical care outside the doors of the clinic and into the community; (2) the enlightened sense —health is shaped by so much more than medical care — even for those who are ill; (3) the restorative sense — the caring dimension is a vital contributor to the healing process; and (4) the fiscal sense — recognition of improving payments and payment structures for prevention and population health.

“Fee-for-service really doesn’t work,” according to McGinnis. The medical community itself if ready to abandon it and it drives a wedge between medicine and public health, he said.

Regardless of the Supreme Court opinion, McGinnis is hopeful: “Even if the Affordable Care Act is overturned, the spirit is there.”

The Supreme Court: Will they or won't they?

We're just about 24 hours away from knowing the fate of the Affordable Care Act and the predictions are in full swing. Will they or won't they? Will they strike the whole thing down or just parts? Will the individual mandate pass muster? What does it all mean for the enormous amount of work that's already been done to implement the law and create the state-based health insurance exchanges? Will the Prevention and Public Health Fund still be around by the end of the week? Will the Medicaid expansion stand? (Does anyone else feel like a 10-year-old in the back seat of your parent's car on a summer road trip — Are we there yet? Are we there yet?)

During yesterday evening's special session on the insanely anticipated Supreme Court decision, panelists took us through the possible decisions and consequences. The running theme on what exactly it all means for the future of our broken health care system? It's too soon to tell. But let's do a quick run-down anyway.

Sarah Somers, managing attorney at the National Health Law Program, said the case before the Supreme Court is actually three separate cases wrapped into one. The four issues before the court are: is the individual insurance mandate constitutional, is the Medicaid expansion constitutional, can the individual mandate be severed from the rest of the law, and can this case even be heard right now. (That last issue is related to a federal statute that says a tax can't be challenged until it has first been assessed.)

When it comes to the mandate, the question is what authority does Congress have to regulate interstate commerce? And while there's no question that health care is interstate commerce, Somers said here's the twist: Congress regulates activity, so is deciding to not buy health insurance an activity or an inactivity? We'll find out tomorrow in what Somers said could be a "dramatic statement about what Congress has the power to do."

On the heels of the mandate is severability. The plaintiffs say that none of the law is severable — if one provision goes, they all go. The feds say different. They say the mandate is severable from everything except some of the law's insurance-related provisions, among them the ban on discriminating against people with pre-existing conditions. (What a misfortunate step backward that would be.)

Next up the law's Medicaid expansion, which would require states to cover people with yearly incomes up to 138 percent of the federal poverty level. According to the Congressional Budget Office, the feds would cover 93 percent of the Medicaid expansion over its first nine years. Still, the plaintiffs claim the expansion is unduly coercive — in other words, the deal is so sweet that the states can't turn it down. Somers said this particular ruling could be huge, as it has big implications for whether the federal government can attach requirements to federal funds.

Lastly, the court could kick the decision down the road until 2014, but observers say it's not likely.

APHA Executive Director Georges Benjamin, who was a panelist during last night's session, noted that the fate of the state-based health insurances exchanges is one of the wild cards. He said he believes the exchanges, which are meant to be competitive marketplaces where residents can buy affordable insurance, can indeed work without the individual mandate. He also commented on how pleased he would be if the landmark Prevention and Public Health Fund is found constitutional. Still, he said that those who think we'll just be going back to the status quo if the law is struck down are wrong. It won't be the status quo, he said, it'll be worse, as implementation of the health reform law is a significant economic driver and job creator.

During the session's Q&A period, a number of attendees called for better messaging around the law, noting how little people actually know about the facts. In response, Somers said to check out the Network for Public Health Law, which has a wealth of information available to all. Also, visit APHA's Supreme Court Case page for even more info.

What are your hopes for tomorrow? Let us know in the comments section below!

Supper time

Midyear Meeting attendees were treated to a tasty dinner spread last night at the Westin Hotel before a special session on the coming Supreme Court decision.

Top photo, APHA President-elect Adewale Troutman, left, talks with a fellow meeting attendee. Middle and bottom photos, meeting attendees grab a bite and catch up.

Addressing health inequities means doing things differently

Parks are great but not if they aren’t located in neighborhoods that face high obesity and diabetes rates. Bike paths are awesome, but they won’t have much of an impact in the community if they aren’t well distributed across the city. And just because we’ve done something a certain way for 20 years isn’t a good reason to keep doing it – particularly when it comes to improving health.

Once again, public health leaders at APHA’s Midyear Meeting are talking about how they are doing things differently to tackle the problem.

A Tuesday session, “Achieving Health Equity: Solutions from the Field,” highlighted local initiatives to underscore health as an issue of justice.



“When we look at what is causing inequities in health, we come to accept it based on evidence. That really, social determinants of health play an enormous role in determining health outcomes,” said Barbara Ferrer, executive director of the Boston Public Health Commission.

Ferrer says the heart and soul of Boston are people of color.

“In those neighborhoods, you will see much worse outcomes. Be it foreclosures, elevated blood levels, higher hospitalization rates."

She and her colleagues have developed a health equity agenda to rid the city of these prevailing health equities that center on reducing low birth weights, tacking obesity, lowering chlamydia rates and building community capacity.



“We’ve really entered into areas where we’ve traditionally not been active,” Ferrer said.

And those efforts are starting to see results.

In 1999, the city was home to 90 dumpster storage lots. Today, there are only 12. Two hundred community garden plots are now in its place. The city has done more work around gun laws, paid sick leave and tobacco control.

“Policies that are good for health aren’t always health policy.”

APHA President-elect Adewale Troutman underscored this notion for the audience. He stressed the need to recognize structural factors that improve health conditions – be it land space, jobs, transportation, air quality.

“You have to ask yourself, can you do this work or do you need to change it and find another mechanism to make it work? Are we willing to take a risk changing society and structure?”